Keith Frederick: The case against Medicaid expansion

Tuesday

Jan 22, 2013 at 1:40 PMJan 22, 2013 at 1:44 PM

Keith Frederick

Glancing at the headlines and editorials from around the state, much of the discussion, at least in the political discourse, revolves around Medicaid and a proposed drastic expansion. I believe we should fix the system we have first before we consider expanding it further. In fact, the expansion will cost taxpayers billions over the next several years. I believe that the federal government will contribute less and less to our state Medicaid system in the future as it calls for the states to “pay their fair share”. If that happens, and we have taken on hundreds of thousands of new people on the Medicaid roles, Missouri will be left with huge expenses and could lead to further reductions to our support of elementary and secondary education as well as higher education in our state and other important areas of our budget. The alternative to that would be the imposition of large tax increases on Missourians at a time when successful states are reducing or eliminating their state taxes. I have adamantly opposed the proposal to expand Medicaid because I believe it is folly to expand a program that is widely recognized to have severe shortcomings including worse outcomes for patients than traditional insurance and sometimes even worse than those with no insurance at all. In addition, the cost to Missouri taxpayers is huge and growing. Even though as a state we spend huge amounts of money on Medicaid, the program compensates providers at very low rates. Often, this rate is barely above 50% of what the same provider would receive in payment from Medicare – the federal health insurance program for our nation’s senior citizens (and even that rate often cannot match private insurance). Steven Lipstein, CEO of BJC HealthCare, alluded to the ramifications of Medicaid’s low reimbursement rate and its negative impact on healthcare costs in an article appearing on STLToday.com on January 15, 2013. I would encourage you to read it – the link is below. One consequence of Medicaid expansion in Missouri beyond the severe financial burden to our taxpayers is that it will very likely result in reduced access to care for our most vulnerable populations. If the Medicaid roles are expanded by some 250-300,000 people, many physicians that are now participating only due to a sense of moral obligation in spite of the fact that it does not make financial sense, may cease to participate. If a doctor’s practice consists of about 10-15% Medicaid, and then after the expansion that percentage goes up to 20% or higher, the office may choose to stop participating because the financial burden is just too high. Therefore, even though ‘coverage’ may be offered to another couple of hundred thousand people, there may not be a doctor or clinic to go to that accepts Medicaid, so the situation would be worse for the patients currently covered by Medicaid. What we need to do is fix our current Medicaid system. I have been working to find ways to do just that, and I believe I may be uniquely qualified in the house to find ways to accomplish this. I attended a conference in Florida called the Medicaid Cure Summit and spoke with experts from around the country about these issues. These solutions will be complex, and discussions will need to get “deep in the weeds”, considering such things as risk adjusted capitated rates and whether to include ABD populations (aged, blind and disabled), whether to include long term care and pharmacy benefits as part of the reform. We will need to engage the medical communities in these discussions. There will be philosophic considerations as we grapple with ideas such as rewarding people with a credit ($10-$100) for various healthy behaviors like smoking cessation (things people should be doing for their own good anyway). If such ideas have been shown to improve health outcomes and save the taxpayer money perhaps we should do it even though we may have some philosophical objections to the plan.

Another reason I oppose this expansion is that the money coming from the federal government is not ‘free money’. This money being spent by our federal government is being borrowed on charge cards made out in the name of our children and grandchildren. Forty percent of the funds the federal government spends are borrowed, and this, in my opinion, is financial child abuse. Why is it that we choose to spend money we don’t have, and place our debt on those who have no voice? It is outrageous- and we should do all we can to stop it now. The easy path to follow as a politician is to give out goodies, benefits, and freebies. Unfortunately the politicians in Greece are reaping the rewards of that type of policy in the form of civil unrest due to austerity measures and drastic cutbacks on benefits that the populace has come to expect. Those in the U.S. who advocate spending billions we do not have perhaps believe they won’t be around when that sort of unrest comes to the U.S. Maybe they won’t or maybe they will be out of politics, but the fact that they may be out of the spotlight and won’t be held accountable doesn’t change the cold hard fact that anyone with a brain knows- you can’t continue to spend more than you have and think everything will work out fine. Am I an alarmist? I don’t think so- I think a fiscal crisis is not just a real possibility; it is a likelihood, if our federal government continues to spend at the current rate, and continues to rack up huge debt. I have received a few automated emails that encourage me to support expansion of the Medicaid roles, but no one mentions the fact that the bill for this would be born largely by our youngsters and those not yet born in the form debt and future taxes to pay it down. Why should we punish our children and those not yet born who have no way to object to the burdens we are placing on them? If you think about it, it is really grossly unfair. In my way of thinking, if it is such a good idea, pay for it with the money you have.

For these reasons and several more, simple Medicaid expansion, as President Obama and Governor Nixon have proposed, will only exacerbate a broken system. Even worse, it costs taxpayers billions in borrowed money with no end to the unprecedented deficit spending in sight. As the federal government requires states to pay more for Medicaid as “their fair share”, the bill to Missouri would climb and crowd out important budget items like education. Poor health outcomes, poor access to health services, and huge expense to the taxpayers- this is not a recipe for success. And yet, simple expansion of Medicaid is the only solution the left has offered. I will be working with my colleagues on both sides of the aisle to propose ways to transform Medicaid and not just kick the can down the road and saddle our children with debt in the process. There is a lot more to come on this issue, and I will try to keep your finger on the pulse as we begin to discuss the options. I want to hear your thoughts.

Activity on the House Floor

This week saw limited debate on the House floor. One item we took up was to establish the rules of the House and we approved those rules that govern the proceedings here at the Capitol. They are fairly dry and into the weeds. One decision we made this year however was to require more transparency in the legislative process. Since I have been a Representative it has been required that if you are going to be recognized by the Speaker to offer an amendment to a bill that is being considered by the House, the amendment has to be reduced to writing and filed with the Chief Clerk and then distributed to the full House. This used to be done by photo copying the amendment and putting a copy on the desk of each Representative, all 163 of them. Two years ago, we began to distribute these amendments, as well as the underlying bill electronically using a system available on each of our laptops on our desks. This allowed each of us to see the underlying bill and all amendments that were being proposed, and that is still the case under our current rules. However, an amendment to the amendment or a substitute amendment did not have to be distributed in the same fashion, but could be read aloud. This year, we have required that even an amendment to the amendment or a substitute amendment will need to be reduced to writing and distributed to all members before the Representative will be recognized to introduce the amendment. How many of you remember the remark by Nancy Pelosi during the debate over ObamaCare when she said, “We are going to have to pass the bill to find out what is in it”. That really made me mad at the time, and even more so now that we are in fact finding out what actually was in the bill. Regardless of how one feels about that law, the method by which it was passed and the fact that so few legislators had actually read and understood the provisions of the bill should be something that we all object to. The new rule we adopted I hope will result in a more complete understanding of each and every provision we are voting on by the Representatives. It has the potential of slowing things down and preventing us from fixing things that need to be fixed ‘on the fly’ so to speak. However, our leadership tells us they intend to be patient and allow the process to work, but they are hopeful that the change will result in a better understanding of the issues being discussed before the vote is taken and for now I agree with that point of view. We will have to see how it works out in practice. Our rules are something that can be revisited and changed in the middle of a session if it is necessary.

Committee Chair Training

Thursday I attended training for my appointment as committee chair to the Committee on Health Care Policy. I received my timeslot for regular weekly hearings and hearing room assignment. My committee will meet on Wednesday’s at noon in House Hearing Room 6. If you are in the capitol at that time, you may want to stop in and see what bills we are hearing. During the session held for Committee Chairmen (and Chairwomen) a number of very experienced previous chairpersons made presentations regarding the nuts and bolts of how to effectively run a committee. Presentations were made regarding overall goals and intentions of the Committee hearing process, the importance of allowing fair hearings, and allowing the interested parties to express their opinions. We were told of ways to facilitate participation from committee members and the public. A point was made to be particularly attentive to individuals who may be coming to the Capitol to testify at a hearing for the first time. I often have noted this in our hearings and I hope to put people at ease when they come to testify and help facilitate their participation. After all, the lobbyists that come to testify are for the most part grizzled veterans, while a citizen from back home in the district may be taking off work, and making other sacrifices to come and be a part of the process, we elected officials, especially the Rep from the person's district should help them have their input with as little difficulty as possible. If you decide to come to Jeff City to provide us input on an issue you care about, come to my office and I and Joyce will help you any way we can. Many of you who come up to Jeff City know that it is not intimidating, and it can be fun. All of this Committee activity has to be done within the time constraints that exist. After testimony, the Committee has to weigh the issues involved and I and the Committee members have to decide how to proceed with the bill in question. There was discussion of how to include the media in the process so those who cannot attend the hearings, but are interested in the proceedings, are able to learn about the issues and how the discussions went. There was some discussion of how to assure that proper decorum is maintained, again all with the goal of making sure that the public has the opportunity to influence their government and the decisions that are made on their behalf. Having attended many committee hearings these past two years, and having served as Vice Chairman of the Health Care Policy Committee, I was familiar with most of these ideas and concerns but still found the sessions very helpful as we make plans to move forward.

The Governor’s Inauguration

Governor Jay Nixon was sworn in for his second term as the state’s 55th governor. The brisk morning began with a worship service at the First Baptist Church in downtown Jefferson City at 8:30 followed by a parade at 10:00. The parade had 10 marching bands along with mascots representing the major sports teams, various military, police and fire departments. After the parade the inaugural ceremony was held on the South Lawn of the Capitol. As temperatures remained in the 20’s, the lawn soon filled with a large crowd seated to witness the swearing in. I understand that under the stage heaters were placed for warmth, though Lt. Governor Peter Kinder and his guest kept warm with a blanket covering their legs. The ceremony was filled with a plethora of activities. Performance by the 135th Army Band, presentation of colors by a joint service color guard, the pledge of allegiance and the National Anthem. Four of the six executive branch elective officials were given the oath of office. The officials were Attorney General Christopher Koster, State Treasurer Clint Zweifel, Secretary of State Jason Kander and Lieutenant Governor Peter Kinder. The oath of office for Governor Nixon was administered by Rex Burlison, Judge of the 22nd Judicial Circuit Court. Governor Nixon was sworn in with his hand placed on the family bible. Next a 19-gun salute was led by the 129th Field Artillery Regiment prior to the Governor’s inaugural address.

Parade

During Nixon’s address he spoke of Missouri’s bloody history in the Civil War and the divided government that led Missouri at that time. He said that, “The people of Missouri are tough and resilient … In good times and bad, through hellish drought and high water, the people of Missouri have proved their mettle. And, as we’ve seen these past few years, when our backs are against the wall, we come together.” He encouraged Democrats and Republicans to come together of the common good. The ceremony concluded with another performance by the Army band, a benediction and Retirement of Colors.

Inauguration Ceremony

Beginning at 1:30 the Governor and Mrs. Nixon greeted the public on the first floor of the mansion. Long lines filled the lawn of the mansion winding through tents and finally to the entrance of the mansion. Marilyn and I managed to hang in there despite the cold temperatures to attend the reception.

The Inaugural Ball took place in the Capitol Building while a live orchestra played in the first floor rotunda. All four floors were filled with party goers in tuxedos and beautiful gowns. The Grand March began at 7:00 p.m. This is when the Legislators and their family members are introduced followed by the executive branch of elected officials. We are presented at the top of the grand staircase and then we walk down the stairs, rotating from the left or right staircases. The Grand March ends once the Governor has been introduced. And now the Ball begins.

Most Senate and Representative offices held receptions for their guest and constituents who may have been attending. My office was busy most of the evening as well. I along with Marilyn enjoyed greeting our guest throughout the evening. If you were able to attend, I want to thank you for stopping by.

If you have suggestions or comments for me about particular issues or just in general, I want to hear from you. Email me at Keith.Frederick@house.mo.gov or call at 573 751 3834. My Legislative Assistant’s name is Joyce Bush and you will find her very experienced, capable and most willing to help also. If you would like to come to the Capitol for a visit, my office is 415-A. Call ahead if you can and we will try to arrange an activity or two for you to enjoy your beautiful Capitol building.

Until my next Capitol Report, I am, and remain, humbly in your service.

Please contact me at:

201 West Capitol Avenue, Room 415-A

Jefferson City, MO 65101-6806

Phone: 573-751-3834

Email: Keith.Frederick@house.mo.gov

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